Question

Class/Group Sne Date Scenario TCsa 49 year-old woman who underwent a vaginal hysterectomy and right salpingo-oophorectomy or abdominal pain and endometriosis. Intraoperatively, she had an intra-abdominal hemorrhage, requir the postanesthesia care unit (PACU) ng transfusion with 3 units of packed red blood cells (RBCs). T.C. is now being admitted to your unit from TCS vital signs are 130/70,94.16,99.7 F(37.6 C). Respirations are shallow and her Spo, is 93% with ygen at 2 L by nasal cannula. She is easily aroused and oriented to place and person. She dozes between verbal requests. She has a low-midline abdominal dressing that is dry and intact, and a Jackson-Pratt drain that is fully compressed and has a scant amount of bright red blood. Her indwelling urinary catheter has clear yellow urine. She is receiving an V of 1000ml DS 45NS at 100 mL/hr in her left foreatm, with no swelling or redness. T.C. is receiving IV morphine sulfate for pain control through a patient-controlled analgesia (PCA) pump. The settings are dose 2 mg, lock-out interval 20 minutes, 4-hour maximum dose of 30mg When anroused, she says that her pain is an 8 on a scale of 1 to 10. 1. What concerns you most right now about T.C. and why? au shallr, spo is 13% reospiatims adch hen uBnd trarshusiU 0gen pang out of 10 2. Identify 3 factors likely affecting T.Cs respiratory status. pin 3. Name 5 interventions you need to implement to promote T.Cs respiratory status.

Answer 1

Answer: Some of the concern that need to be addressed are:

• Respiration are shallow and SPO is 93%
• Scant amount of blood
• Pain that is 8 on scale of 10.

The three factors affecting respiratory status are:

• Pain
• Morphine administration.

The nursing intervention to promote respiratory status are:

• Make the patient to lie down straight to promote oxygen facility.
• Encourage respiratory exchange of gases.
• Hydration should be maintain by using modifiers.
• Improve pulmonary ventilation.
• Encourage lip breathing.